Care home fined after woman, 93, dies trapped in her bed

Elsie Beals was found asphyxiated at the Aden Court Care Home in Birkhouse Lane, Huddersfield, on April 24, 2010 during a routine check in the middle of the night.

Leeds Crown Court heard she had been put to bed as usual but had slipped down a gap between her top mattress and the side rails, installed to stop her falling out of bed.

Judge Penelope Belcher heard at the time staff at the home had not been given formal training on the use of the rails or the risks associated with them.

New Century Care Ltd, part of a group which has 27 care homes around the country, was also ordered to pay £18,000 costs yesterday after admitting a breach of health and safety regulations. Fining the firm, the judge said alarm bells should have rung sooner because records showed Mrs Beals had injured her leg trapping it in the rails on two previous occasions.

She accepted it was not a “rogue home” where there was deliberate abuse or neglect. “This case could not have been further from that,” she said.

“This home genuinely cared about its residents, genuinely sought to provide for them with proper, adequate care.”

But she said the rails issue amounted to an “obvious and glaring oversight,” and serious injury and death were eminently foreseeable.

“What is abundantly clear is that staff at the home undoubtedly cared for their residents but they simply were not provided with the right information and training.”

Sam Green, prosecuting, said after the earlier incidents involving Mrs Beals, staff had sometimes used a rolled duvet to plug the gap.

Investigation later revealed the bed rail was incorrectly installed and too wide for the bed.

They were mounted in such a way as to leave a 95mm gap between the rail and top pressure mattress and because of flexibility in the rail there was a possible further 15mm sideways movement.

Ben Compton QC expressed regret on behalf of the company and said the rails had been withdrawn and replaced throughout its operations and revised guidance given to staff.

Mrs Beals, a retired shopworker, previously lived with her late husband Jack in the Lepton area of Huddersfield.

After the case her cousin Jean Oliver said she hoped the tragedy and publicity would lead to better safety for others in care homes. “Nobody deserves to die like that,” she added.